Get 855 232 3596

This guide provides step-by-step instructions for completing the 855 232 3596 Electronic Funds Transfer (EFT) Authorization Agreement Form. By following these instructions, you can ensure that your form is filled out accurately, expediting the enrollment process.

Follow the steps to accurately complete the form.

1. Press the ‘Get Form’ button to access the 855 232 3596 form and open it in your online editor.
2. Begin by filling in the provider information, which includes your provider name, doing business as name (DBA), and complete address, including street, city, state, and ZIP code.
3. Next, provide your provider identifiers, including your Federal Tax Identification Number (TIN) or Employer Identification Number (EIN) and National Provider Identifier (NPI). Ensure that the NPI number is completed if applicable.
4. Fill in your contact information, including the provider contact name, telephone number, email address, and fax number.
5. Enter your financial institution information, such as the name and address of the financial institution, routing number, and your account number. Ensure that the account type is selected (checking or savings).
6. In the submission information section, indicate the reason for submission by selecting from the options: new enrollment, change enrollment, or cancel enrollment. You will also need to confirm if you are including a voided check or bank letter.
7. Sign the authorization agreement, ensuring that the signature is from an authorized individual. Include their printed name and title.
8. Review all sections to confirm that each part of the form is completed accurately and legibly to avoid delays.
9. Once the form is complete, save the changes, and you can submit the form by fax or email as indicated in the instructions.

Complete the 855 232 3596 form online today to streamline your Electronic Funds Transfer enrollment.